Provider Demographics
NPI:1023665288
Name:CLARK, JEFFREY (PHARMD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 SPANISH FIELDS DR
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-4519
Mailing Address - Country:US
Mailing Address - Phone:801-471-9312
Mailing Address - Fax:
Practice Address - Street 1:1117 W 400 S
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-3061
Practice Address - Country:US
Practice Address - Phone:385-685-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5910037183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist